Basic Information
| Provider Information | |||||||||
| NPI: | 1104824739 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH IDAHO DAY SURGERY LLC | ||||||||
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| OtherOrganizationName: | NORTHWEST SPECIALTY HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1593 E POLSTON AVE | ||||||||
| Address2: | |||||||||
| City: | POST FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838545326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082622300 | ||||||||
| FaxNumber: | 2082622390 | ||||||||
| Practice Location | |||||||||
| Address1: | 1593 E POLSTON AVE | ||||||||
| Address2: | |||||||||
| City: | POST FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838545326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082622300 | ||||||||
| FaxNumber: | 2082622390 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2005 | ||||||||
| LastUpdateDate: | 08/04/2022 | ||||||||
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| AuthorizedOfficialLastName: | RASMUSSEN | ||||||||
| AuthorizedOfficialFirstName: | RICK | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2082622320 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 65 | ID | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 823016 | 01 | FIRST HEALTH | OTHER | 00471 | 01 | ID | BLUE CROSS OF IDAHO | OTHER | 000010145102 | 01 | ID | REGENCE BLUE SHIELD | OTHER | 23166 | 01 | GROUP HEALTH | OTHER | 0179400 | 01 | WASHINGTON WORKER COMP | OTHER | 806752000 | 05 | ID | MEDICAID | 2031331 | 05 | WA | MEDICAID | 7031222 | 01 | WASHINGTON MEDICAID | OTHER | 1006277 | 01 | ID | STATE INSURANCE FUND | OTHER |